Anthologies in Vascular Surgery-12 : Indian Journal of Vascular and Endovascular Surgery

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Anthologies In Vascular Surgery.12

Anthologies in Vascular Surgery-12

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Indian Journal of Vascular and Endovascular Surgery 9(5):p 426-427, Oct–Dec 2022. | DOI: 10.4103/0972-0820.367733
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Compiler & Reviewer: Dr. P. Ilaya kumar, MMC, Chennai.


European Society for Vascular Surgery (ESVS) 2023 clinical practice guidelines on the Management of Atherosclerotic carotid and Vertebral Disease

Ross Naylor et al. Eur J Vasc Endovasc Surg. 2022 May20;S1078-5884 (22) 00237-4.

DOI: 10.1016/j.ejvs.2022.04.011.

This document contains 133 recommendations, including 38 that are new and 11 that have been 'regraded' since 2017, which is when the last ESVS guidelines on this topic were published. The manuscript contains 629 references, 289 of which are new (i.e. published between 2017 and 2022). Thirty-nine of the references are from randomised controlled trials, 71 are systematic reviews and/or meta-analyses, and the references also include data from 50 vascular registries or quality initiative programmes.

In the document, the authors first address what is new in the 2023 guidelines. They have mentioned that each section has been revised or rewritten and five new sections have been added:

  • Management of free floating thrombus (Recommendations 58-60)
  • Management of carotid webs (Recommendation 61)
  • Management of symptomatic patients with an ipsilateral 50–99% carotid stenosis and atrial fibrillation (Recommendation 63)
  • Planning carotid interventions in anticoagulated patients
  • Timing of carotid interventions in patients with acute ischemic stroke undergoing thrombolysis.(Recommendation 49).

Naylor, Rantner and colleagues add, that the new guidelines highlight similarities and discrepancies with the 2021 American Heart Association (AHA) guidelines on the management of stroke/transient ischemic attack (TIA), the 2021 European Stroke Organisation (ESO) guidelines on carotid endarterectomy (CEA) and carotid artery stenting (CAS), the 2021 German-Austrian guidelines on the management of carotid disease, and the 2021 Society for Vascular Surgery (SVS) guidelines on the management of patients with carotid and vertebral artery disease.

In addition, the authors note that a series of unanswered questions in the 2017 guidelines were highlighted as being priorities for future research. “These involved scenarios where there were either no data, or conflicting evidence that did not allow recommendations to be made,” they elaborate. The current guidelines have addressed some of these questions, which include: Is there a validated algorithm for identifying 'higher risk for stroke' ACS [asymptomatic carotid stenosis] patients? Does ACS cause cognitive decline and can this be reversed or prevented by CEA or CAS? And which recently symptomatic patients with <50% stenosis might benefit from urgent CEA or CAS?. A must read for all carotid enthusiasts!.


Surgery or Endo-vascular Theraphy for Chronic Limb-Threatening Ischemia

A. Farber, M.T. Menard, et al

DOI: 10.1056/NEJM oa 2207899. Published Nov 7,2022,

The long awaited Best Endo-vascular vs Best surgical Theraphy (BEST-CLI Trial) in patients with CLTI is finally out, decades of endo vs surgery debate is to an extent laid to rest by the results arrived to in the study.

This international multi-center randomized trial enrolled 1830 patients suffering from CLTI and infra-inguinal PAD into two parallel-coharts, Thus, Patients who had a single-segment of GSV available for Bypass were placed in cohort 1, and patients who needed an alternate conduit were placed in cohort 2. The primary outcome evaluated was a composite of a major adverse event defined as amputation Above the ankle or a major limb intervention (new bypass graft or graft revision, thrombectomy or Thrombolysis) or death from any cause.

After a median follow-up of 2.7 years/In cohort 1, primary outcome event occurred in 302 of 709 patients (42.6%) in the surgical group and in 408 of 711 patients (57.4%) in the endo-vascular group. In the cohort 2, a primary outcome event (MALE or Major limb intervention (new bypass or graft revision, thrombectomy, thrombolysis or death) occurred in 83 of 194 patients (42.8%) in the surgical group and in 95 of 199 patients (47.7%) in the endo-vascular group after a median follow-up of 1.6 years, the incidence of adverse events being similar in the two groups.

The study concluded that in patients who had a good conduit for surgical bypass (cohort1) the incidence of MALE or death was significantly lower in the surgical group than in the endo group. In patients who lacked an adequate conduit (cohort2) the outcomes in both the groups were similar.

The study has few limitations;

  1. Selection and operator bias, since eligibility was determined locally and by individual operators and their expertise.
  2. The percentage of women enrolled in the trial (28%) was very low.
  3. Since additional funds were required for the 24 month follow-up, full follow-up was not done in cohort 2.
  4. The safety profile of Paclitaxel-coated balloons and stents were in question towards the end of the trial period, hence reduced use of Drug-coated balloons and stents, which could have altered the trial results more in favour of endo-vascular group. The study needs further evaluation and follow-up.


Clinical presentation, operative management and long term outcomes of rupture after previous abdominal aortic repair

Indrani sen MD, Manju kalra et al., Division of vascular & surgery, Mayo clinic. jvasc surg 2022;1-10.

This single-centre retro-spective cohort study evaluates the presentation, intervention and survival of patients who had been treated for late abdominal aortic aneurysm rupture (LAR) after open repair (OR) or Endovascular aortic aneurysm repair (EVAR) from 2000-2020. The endpoints studied include (1) 30 day mortality rates.(2) Major post-operative complications.(3) Survival. The outcomes of LAR treated with EVAR (group 1) vs OR (group 2) were compared.

The key findings include;

  1. Amoung the 390 patients, LAR (n = 40) occurred in 30 patients after EVAR and after prior open repair (OR) 10 patients.
  2. The time to LAR was shorter in EVAR group (6+/-4 yrs) compared with OR (12+/-4yrs), p=0.003. The treatment for LAR was EVAR (Group 1) in 25 patients (63%) and OR (Group 2) in15 patients (37%). The incidence of free-rupture, time to treatment, 30 day mortality and complications were similar between the two groups. The overall survival was also similar (28 vs 22 months) between the groups.

The study has a few limitations in that this is a single- centre, retro-spective, hospital-based cohort study with a small sample size and with non-availablity of data and imaging details regarding the index procedures and survilance if any, and also the short term follow -up of the initial EVAR group. In spite of these limitations the study highlights the fact that LAR is more common in practice (1 in10) after both EVAR and OR and can be salvaged by both OR and EVAR with acceptable morbidity and mortality rates and also highlights the need for a good survielence protocol particularly after EVAR.

© 2022 Indian Journal of Vascular and Endovascular Surgery | Published by Wolters Kluwer – Medknow